Surviving Torture, Rocking the Story

Karen Fondacaro, director of Connecting Cultures, meets with pre-doctoral clinicians working with torture survivors. They talk a lot about vicarious trauma, but she also talks about the vicarious resilience that draws them to the field. “The groups are such a privilege to be in,” Fondacaro says. “It is complicated, difficult, intense -- but I would choose nothing else to do now.” (Photo: Sally McCay)

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A group of Somali-Bantu women are gathered in a swirl of festive hijabs, a scene, if viewed from a distance, that belies the intensity of emotion flaring in the room as one refugee recounts her wrenching experience of sexual assault. The story triggers everyone, including two seasoned therapists running the group, two pre-doctoral clinicians, a student transcribing the story, even the interpreter. The collective SUD level (subjective unit of distress) has hit a ten or beyond. Until a creative grad student jumps in to suggest they adapt a mindfulness technique the women, all mothers, relate to instinctively. Through their sobs they “rock the story,” swaying gently, arms folded in front of them as if cradling and soothing an infant.

“It sounds goofy,” says Karen Fondacaro, director of UVM’s Behavior Therapy and Psychotherapy Center, “but it’s all that was said. As a community in this room we’re going to take that story and rock it together. And we’re rocking, and we’re regulating and everyone is coming back to the room.” SUDS are down to five or six. In a few minutes, there’s laughter. The next week, Fondacaro says, everyone was light on her feet. “Something had happened -- it was very powerful.”

It’s been six years since Fondacaro founded Connecting Cultures, a program designed to provide mental health services to Vermont’s refugee community. The clinic has since served more than 300 refugees from 29 different countries. Sixty-seven percent are torture survivors. Those numbers -- and the real lives behind them -- have led Fondacaro to partner with groups both inside and outside of the university to expand the types of services offered to refugees (including legal, social and medical), beginning with the co-founding in 2009 of New England Survivors of Torture and Trauma (NESTT).

With the three-year federal grant funding NESTT (recently renewed), Fondacaro has a mandate to provide psychological services to torture survivors, to empirically evaluate the effectiveness of treatment and to train other providers, which she does at both the national and local level, while also supervising her team of graduate students. It’s also led her to develop and implement new models of care, such as the carefully designed therapy bringing those Somali women together.

Accounting for culture

The center’s new treatment and research model is based on the “third wave” therapy known as ACT (acceptance and commitment therapy), with modifications they are making for a refugee population that has language and other cultural barriers, combined with severe and prolonged trauma, work Fondacaro’s students are in the process of manualizing for other providers.

The first key to the process is to dispense with the need for labels that pathologize torture survivors. Fondacaro often shortens the abbreviation for what many of them suffer to PTS (post-traumatic stress). “These are not disordered people,” she says in a NESTT training session. “The big secret is that we all have the same secret; we are all suffering from these different things that were dealt to us. It takes away the us and them mentality.”

Perhaps most critically, though there’s an element of exposure therapy, a radical difference is putting the timing and control over sharing the story completely in the hands of the torture survivor. “The idea is that it’s your story,” Fondacaro says. “You were given a story that nobody would ever ask for, and you have the right to tell whomever you want or never tell anybody. Having control over the story is really freeing for people.” Once in the groups (so far the center has run four with Bhutanese survivors and one with Somali-Bantu, with two more upcoming), everyone, even the initially reluctant, has voiced -- through an interpreter -- his or her story.

Part of the reason people do open up is that the process is gradual. The clinicians begin by creating a sense of safety and trust, sitting, talking, singing. They teach mindfulness exercises and get to know their clients’ values, often using pictures to represent the refugees’ homeland, marriage, children and asking them how important they are on a scale from one to ten. (This will also help prepare them to rate their SUD level -- “like a thermometer”-- putting a number on their perceived level of anxiety and distress when telling, or hearing, a story.)

And it also begins with respect, including graduate students learning to count to 10 in their clients’ languages. Maggie Evans and Jessica Clifton, both fourth-year pre-doctoral clinicians, immediately laugh when asked how that’s been. “It creates a bit of humor in the room,” says Evans. “I imagine myself butchering some of these numbers, but clients really appreciate the effort." "I think it also helps us relate to them," adds Clifton. "If I’m stumbling over all of these words, how hard is it for them to learn English?”

They also work with cultural consultants to understand the individual countries and the social and political histories that forced people to leave their homes. Lacking that awareness is arrogance on a therapist’s part, according to Fondacaro.

The things they carry

Part of the early therapy is creating visual narratives of their lives, using yarn for a timeline, cutout flowers for the sweet spots and stones for the painful ones. At the NESTT training, Diane Gottlieb, clinical assistant professor of psychology and Connecting Cultures group coordinator, admits she felt a bit ridiculous bringing in craft supplies to a group of Bhutanese men, then stunned at their engagement in the process as the flowers were plentiful, representing a life not utterly defined by torture. “I forgot I had any flowers,” she recalls them saying. “Thank you for showing me my flowers.” And then they begin by telling the sweet stories.

When survivors do share their stones, the unimaginable cruelty and violence, watching their children being killed -- or being forced to choose which child to leave behind -- they are carefully monitored, and their SUDS do go up, but in the process they learn that they can tolerate that. And mindfulness techniques help them cope. If they choose, the scribe reads back the story.

Fondacaro understands that telling and hearing the story, the habituation, is what does work in exposure therapy, but she also believes that, in the case of torture survivors, it fails to credit the impact of the community, that there’s a group of people saying, “We’re here to listen, we accept you and your story that you’ve been hiding for so long.”

Ultimately, and this is the heart of ACT, these stories don’t go away. Survivors don’t get over it, and that isn’t the point. “Being healthy isn’t getting rid of the anxiety or sadness,” Fondacaro says. “The idea is to be able to tolerate it and live a value-rich life.”

If you’re living at a 10, you can’t work, you can’t play with your children, Fondacaro says, but five or six you can carry. Having previously taken to her bed when memories overwhelmed her, one Somali-Bantu woman told Fondacaro with a smile, “I was cooking dinner, and I was just rocking the baby.”